Propensity-matched Cohort Of Patients Research Articles

Impact of Androgen Deprivation Therapy on Lumbar Spine Bone Health Using Quantitative Computed Tomography in a Propensity-Matched Cohort of Patients With Prostate Cancer

Purpose: Fragility fracture risk in patients with prostate cancer is an important issue. The purpose of this study was to accurately assess the impact of androgen deprivation therapy on lumbar spine bone loss using quantitative computed tomography in a propensity-matched cohort of patients with prostate cancer. Materials and Methods: Eighty-one patients with prostate cancer who underwent androgen deprivation therapy for 1 year were included. Thirty-nine of these patients were successfully propensity-matched with 39 of 68 patients from a control group who underwent robot-assisted radical prostatectomy without androgen deprivation therapy. Volumetric bone mineral density of trabecular bone in each vertebral body (L1-L4) was measured using quantitative computed tomography during staging and at 1 year after commencing treatment. The change in mean lumbar volumetric bone mineral density (L1-L4) was then calculated. Results: Propensity score matching successfully achieved comparable baseline patient characteristics and radiological parameters between the androgen deprivation therapy and control groups. In the androgen deprivation therapy group, the decrease in lumbar volumetric bone mineral density (L1-L4) was significantly greater with confirmed testosterone deficiency (−17.9 ± 12.0%) compared with the control group (−8.5 ± 10.8%, P < .001). Conclusions: This study observed a 17.9% reduction in volumetric lumbar bone mineral density (g/cm3) after 1 year of androgen deprivation therapy, exceeding previously reported values (g/cm2) obtained using dual-energy X-ray absorptiometry. The potential overestimation of lumbar spine bone mineral density measured by dual-energy X-ray absorptiometry in older patients with prostate cancer because of concomitant lumbar degenerative disease is a possible reason for this discrepancy. Androgen deprivation therapy may decrease vertebral bone mass and increase the risk of vertebral fractures more than urologists realize.

Editorial Comment: Impact of Androgen Deprivation Therapy on Lumbar Spine Bone Health Using Quantitative Computed Tomography in a Propensity-Matched Cohort of Patients With Prostate Cancer

Editorial Comment: Impact of Androgen Deprivation Therapy on Lumbar Spine Bone Health Using Quantitative Computed Tomography in a Propensity-Matched Cohort of Patients With Prostate Cancer

Therapeutic plasma exchange provides native liver survival benefit in children with acute liver failure: A propensity score-matched analysis.

This study aimed to evaluate the safety and efficacy of therapeutic plasma exchange (TPE) in pediatric acute liver failure (PALF). All children aged 2-18 years with PALF were included. The intervention cohort included a subset of PALF patients undergoing complete three sessions of TPE, whereas the matching controls were derived by propensity score matching from the patient cohort who did not receive any TPE. Propensity matching was performed based on the international normalized ratio (INR), grade of hepatic encephalopathy (HE), age, bilirubin, and ammonia levels. The primary outcome measure was native liver survival (NLS) in the two arms on day 28. Of the total cohort of 403 patients with PALF, 65 patients who received TPE and 65 propensity-matched controls were included in analysis. The 2 groups were well balanced with comparable baseline parameters. On day 4, patients in the TPE group had significantly lower INR (P = 0.001), lower bilirubin (P = 0.008), and higher mean arterial pressure (MAP) (P = 0.033) than controls. The NLS was 46.15% in the TPE arm and 26.15% in the control arm. The overall survival (OS) was 50.8% in the TPE arm and 35.4% in the control arm. Kaplan-Meier survival analysis showed a significantly higher NLS in patients receiving TPE than controls (P = 0.001). On subgroup analysis, NLS benefit was predominantly seen in hepatitis A-related and indeterminate PALF. TPE improved NLS and OS in a propensity-matched cohort of patients with PALF. Patients receiving TPE had lower INR and bilirubin levels and higher MAP on day 4.

Comparison of pulsed field and radiofrequency ablation for non-paroxysmal atrial fibrillation: a propensity score-matched analysis

Abstract Background Ablation of non-paroxysmal atrial fibrillation (AF) is challenging and often requires left atrial substrate ablation. While the pentaspline, multi-electrode pulsed-field ablation (PFA) catheter is approved for pulmonary vein isolation (PVI), its role in procedures involving substrate ablation for nonparoxysmal forms of AF remains unknown. Purpose We conducted a retrospective study to assess the safety and long-term outcomes of PFA for non-paroxysmal AF. Methods Procedural and follow-up data were retrospectively collected for all patients undergoing a first-time ablation for non-paroxysmal AF across two centers, between November 2021 and December 2022. Patients undergoing PFA consisting of PVI, isolation of the posterior wall (PWI) and ablation of the mitral isthmus (MI) with the pentaspline multi-electrode PFA catheter, were compared with patients undergoing radiofrequency ablation (RFA) involving PVI, a roof line or PWI, alcohol ablation of the vein of Marshal (VOM) and MI ablation. Patients were matched using propensity scores to minimize potential confounders. The primary endpoint was arrhythmia (AF/atrial flutter/atrial tachycardia) recurrence after a 90-day blanking period. Results The baseline characteristics of the 116 matched patients are detailed in Table 1. PVI was successful in all patients. In the PFA group, PWI was additionally performed in all patients and MI ablation in 83% of cases, resulting in acute success rates of 97% and 96%, respectively. In the RFA group lesions beyond PVI included: a roof line (90%), PWI (10%), VOM alcohol ablation (93%) and MI ablation with ablation in the coronary sinus (CS) if needed (97%). Procedural block across the roof and the MI was achieved in 96% and 95%, respectively and complete PWI in 83% of cases. The PFA group had a shorter total procedure (84.2±22.3 vs 117.3±24.8 min, p<0.001) but a longer fluoroscopy time (23.1±7.2 vs 16.8±6.3 min, p<0.001). The difference in radiation dose, however, was not statistically significant (57.7±74.1 Gy.cm2 in the PFA vs 49.8±53.6 Gy.cm2 in the RFA group, p=0.24). The overall periprocedural complication rates were similar in both groups (8.6% PFA vs 12.1% RFA, p=0.76), with no cardiac tamponades or deaths. Group-specific complications included 1 coronary spasm in the PFA group and 1 CS dissection in the RFA group. During a median follow-up of 447 days (IQR: 364-552), 1 stroke occurred in each group and 1 sudden cardiac death in the RFA group, 13 months post-procedure. Both groups had similar rates of recurrences (32.8% PFA vs 25.9% RFA, p=0.54). Arrhythmia-free survival probability at 16 months was estimated at 67.2% for PFA and 77.6% for RFA by Kaplan-Meier analysis (p=0.16, Figure 1). Conclusions In this propensity-matched cohort of patients with non-paroxysmal AF, PFA and RFA demonstrated similar complication rates and arrhythmia-free survival at follow-up. The procedure duration, however, was significantly shorter with PFA.Figure 1

Effect of on-pump vs. off-pump coronary artery bypass grafting in patients with non-dialysis-dependent severe renal impairment: propensity-matched analysis from the UK registry dataset.

On-pump coronary artery bypass (ONCABG) grafting in patients with a pre-existing poor renal reserve is known to carry significant morbidity and mortality. There is limited controversial evidence on the benefit of off-pump coronary artery bypass (OPCABG) grafting in these high-risk groups of patients. We compared early clinical outcomes in propensity-matched cohorts of patients with non-dialysis-dependent pre-operative severe renal impairment undergoing OPCABG vs. ONCABG, captured in a large national registry dataset. All data for patients with a pre-operative creatinine clearance of less than 50 mL/min who underwent elective or urgent isolated OPCABG or ONCABG from 1996 to 2019 were extracted from the UK National Adult Cardiac Surgery Audit (NACSA) database. Propensity score matching was performed using 1:1 nearest neighbor matching without replacement using several baseline characteristics. We investigated the effect of ONCABG vs. OPCABG in the matched cohort using cluster-robust standard error regression. We identified 8,628 patients with severe renal impairment undergoing isolated CABG, of whom 1,142 (13.23%) underwent OPCABG during the study period. We compared 1,141 propensity-matched pairs of patients undergoing OPCABG vs. ONCABG. The median age of the matched population was 78 years in both groups, with no significant imbalance post-matching in the rest of the variables. There was no difference between OPCABG and ONCABG in in-hospital mortality rates, post-operative dialysis, and stroke rates. However, the return to theatre for bleeding or tamponade was higher in ONCABG vs. OPCABG (P > 0.02); however, OPCABG reduced the total length of stay in the hospital by 1 day (P = 0.008). After double adjustment in the matched population using cluster-robust standard regression, ONCABG did not increase mortality compared to OPCABG (OR, 1.05, P = 0.78), postoperative stroke (OR, 1.7, P = 0.12), and dialysis (OR, 0.7, P = 0.09); however, ONCABG was associated with an increased risk of bleeding (OR, 1.53, P = 0.03). In this propensity analysis of a large national registry dataset, we found no difference in early mortality and stroke in patients with pre-operative severe renal impairment undergoing OPCABG or ONCABG surgery; however, ONCABG was associated with an increased risk of return to theatre for bleeding and an increased length of hospital stay.

Determinants and Outcomes Associated With Skilled Nursing Facility Use After Coronary Artery Bypass Grafting: A Statewide Experience.

Skilled nursing facility (SNF) care is frequently used after cardiac surgery, but the patterns and determinants of use have not been well understood. The objective of this study was to evaluate determinants and outcomes associated with SNF use after isolated coronary artery bypass grafting. A retrospective analysis of Medicare Fee-For-Service claims linked to the Society of Thoracic Surgeons clinical data was conducted on isolated coronary artery bypass grafting patients without prior SNF use in Michigan between 2011 and 2019. Descriptive analysis evaluated the frequency, trends, and variation in SNF use across 33 Michigan hospitals. Multivariable mixed-effects regression was used to evaluate patient-level demographic and clinical determinants of SNF use and its effect on short- and long-term outcomes. In our sample of 8614 patients, the average age was 73.3 years, 70.5% were male, and 7.7% were listed as non-White race. An SNF was utilized by 1920 (22.3%) patients within 90 days of discharge and varied from 3.2% to 58.3% across the 33 hospitals. Patients using SNFs were more likely to be female, older, non-White, with more comorbidities, worse cardiovascular function, a perioperative morbidity, and longer hospital lengths of stay. Outcomes were significantly worse for SNF users, including more frequent 90-day readmissions and emergency department visits and less use of home health and rehabilitation services. SNF users had higher risk-adjusted hazard of mortality (hazard ratio, 1.41 [95% CI, 1.26-1.57]; P<0.001) compared with non-SNF users and had 2.7-percentage point higher 5-year mortality rate in a propensity-matched cohort of patients (18.1% versus 15.4%; P<0.001). The use of SNF care after isolated coronary artery bypass grafting was frequent and variable across Michigan hospitals and associated with worse risk-adjusted outcomes. Standardization of criteria for SNF use may reduce variability among hospitals and ensure appropriateness of use.

Sleep Testing and Mortality in a Propensity-matched Cohort of Patients with Chronic Obstructive Pulmonary Disease.

Rationale: Many advocate the application of propensity-matching methods to real-world data to answer key questions around obstructive sleep apnea (OSA) management. One such question is whether identifying undiagnosed OSA impacts mortality in high-risk populations, such as those with chronic obstructive pulmonary disease (COPD). Objectives: Assess the association of sleep testing with mortality among patients with COPD and a high likelihood of undiagnosed OSA. Methods: We identified patients with COPD and a high likelihood of undiagnosed OSA. We then distinguished those receiving sleep testing within 90 days of index COPD encounters. We calculated propensity scores for testing based on 37 variables and compared long-term mortality in matched groups. In sensitivity analyses, we compared mortality using inverse propensity weighting and instrumental variable methods. We also compared the incidence of nonfatal events including adverse outcomes (hospitalizations and COPD exacerbations) and routine services that are regularly indicated in COPD (influenza vaccination and pulmonary function testing). We compared the incidence of each nonfatal event as a composite outcome with death and separately compared the marginal probability of each nonfatal event independently, with death as a competing risk. Results: Among 135,958 patients, 1,957 (1.4%) received sleep testing. We propensity matched all patients with sleep testing to an equal number without testing, achieving excellent balance on observed confounders, with standardized differences < 0.10. We observed lower mortality risk among patients with sleep testing (incidence rate ratio, 0.88; 95% confidence interval [CI], 0.79-0.99) and similar results using inverse propensity weighting and instrumental variable methods. Contrary to mortality, we found that sleep testing was associated with a similar or greater risk for nonfatal adverse events, including inpatient COPD exacerbations (subhazard ratio, 1.29; 95% CI, 1.02-1.62) and routine services like influenza vaccination (subhazard ratio, 1.26; 95% CI, 1.17-1.36). Conclusions: Our disparate findings can be interpreted in multiple ways. Sleep testing may indeed cause both reduced mortality and greater incidence of nonfatal adverse outcomes and routine services. However, it is also possible that our findings stem from residual confounding by patients' likelihood of accessing care. Given the limitations of propensity-based analyses, we cannot confidently distinguish these two possibilities. This uncertainty highlights the limitations of using propensity-based analyses to guide patient care and policy decisions.

Prophylactic Administration of Vasopressors Prior to Emergency Intubation in Critically Ill Patients: A Secondary Analysis of Two Multicenter Clinical Trials.

A secondary analysis of two multicenter randomized clinical trials. The clinical effect of prophylactic vasopressor administration was estimated using a one-to-one propensity-matched cohort of patients with and without prophylactic vasopressors. Seven emergency departments and 17 ICUs across the United States. One thousand seven hundred ninety-eight critically ill patients who underwent emergency intubation at the study sites between February 1, 2019, and May 24, 2021. None. The primary outcome was peri-intubation hypotension defined as a systolic blood pressure less than 90 mm Hg occurring between induction and 2 minutes after tracheal intubation. A total of 187 patients (10%) received prophylactic vasopressors prior to intubation. Compared with patients who did not receive prophylactic vasopressors, those who did were older, had higher Acute Physiology and Chronic Health Evaluation II scores, were more likely to have a diagnosis of sepsis, had lower pre-induction systolic blood pressures, and were more likely to be on continuous vasopressor infusions prior to intubation. In our propensity-matched cohort, prophylactic vasopressor administration was not associated with reduced risk of peri-intubation hypotension (41% vs 32%; p = 0.08) or change in systolic blood pressure from baseline (-12 vs -11 mm Hg; p = 0.66). The administration of prophylactic vasopressors was not associated with a lower incidence of peri-intubation hypotension in our propensity-matched analysis. To address potential residual confounding, randomized clinical trials should examine the effect of prophylactic vasopressor administration on peri-intubation outcomes.

Is Hand Therapy Associated With a Delay in Surgical Treatment in Thumb Carpometacarpal Arthritis?

Thumb carpometacarpal (CMC) osteoarthritis (OA) causes functional disability and an increased health care burden in the aging population. The role of therapy in thumb CMC OA has been minimally analyzed in the literature. We hypothesized that patients treated with therapy for thumb CMC OA would demonstrate reduced rates of surgery for this diagnosis. We queried a national insurance dataset for all patients with an International Classification of Diseases, Ninth Revision, or International Statistical Classification of Diseases, Tenth Revision, code for thumb CMC OA, with a minimum of 2 years of follow-up. A 2:1 propensity-matched cohort of patients with CMC OA who did not receive therapy versus a therapy cohort was created, with a minimum of two sessions of hand therapy for inclusion. The primary outcome was the rate of thumb CMC OA surgery occurring within 2 years of diagnosis; time to surgery and use of thumb CMC injections were secondary outcomes. Multivariable logistic regression analysis was used to identify the risk factors for undergoing surgical treatment. After matching, the therapy cohort comprised 14,548 patients, with a matched group of 28,930 patients who did not undergo therapy. In the overall sample, the rate of surgery within 2 years was 22.5%. Two-year surgical treatment rates were significantly higher for those who did not undergo therapy when compared with those who did (29.3% vs 13.1%). Patients treated with therapy had a significantly longer time to surgery, with no difference in the rate of surgery after one year. In multivariable regression of all included variables, lack of therapy intervention had the highest odds of surgery for thumb CMC OA (odds ratio 4.3). We present the findings of a large insurance database evaluating the association of therapy with rates of surgical treatment for thumb CMC arthritis. On average, those treated with therapy had longer times to surgery, and the 2-year surgery rates for patients diagnosed with thumb CMC arthritis were significantly higher in those who did not undergo therapy treatment. Prognostic II.

Midvastus Versus Medial Parapatellar Approach in Simultaneous Bilateral Total Knee Arthroplasty

BackgroundThe purpose of this study was to compare the postoperative outcomes over a period of 3 years in patients who underwent bilateral total knee arthroplasty (TKA) using midvastus (MV) versus medial parapatellar (MPP) approaches. MethodsIn this retrospective study, 2 propensity-matched cohorts of patients who underwent simultaneous bilateral TKA via MV (n = 100) and MPP (n = 100) approaches from January 2017 to December 2018 were compared. Surgical parameters compared were surgery time and the incidence of lateral retinacular release (LRR). Clinical parameters including the visual analog score for pain, time for straight leg raise (SLR), range of motion, the Knee Society Score, and the Feller patellar score were assessed in the early postoperative and follow-up periods up to 3 years. Radiographs were evaluated for alignment, patellar tilt, and displacement. ResultsLRR was performed on 17 knees (8.5%) in the MPP group and 4 knees (2%) in the MV group which was significant (P = .03). The time to SLR was significantly lower in the MV group. There was no statistically significant difference in the length of hospital stay between the groups. The visual analog score, range of motion, and Knee Society Score were better in the MV group within 1 month (P < .05), but no statistically significant differences were found later. Patellar scores, radiographic patellar tilt, and displacements were similar at all follow-up periods. ConclusionIn our study, the MV approach had faster SLR, less LRR, and better pain and function scores in the first few weeks after TKA. However, its effect on different patient outcomes has not been sustained at 1 month and further follow-up points. We recommend that surgeons use the surgical approach with which they are most familiar.

Hepatectomy versus sorafenib for advanced hepatocellular carcinoma with macroscopic portal vein tumor thrombus: A bi-institutional propensity-matched cohort study.

Sorafenib was previously considered a first-line treatment for hepatocellular carcinoma (HCC) patients with macroscopic portal vein tumor thrombus (PVTT). This case-matched analysis was performed to evaluate the best first-line treatment for HCC in patients with macroscopic PVTT. The HCC patients with Vp2 (PVTT invaded into a second-order portal branch), Vp3 (first-order portal branch), and Vp4 (main trunk or contralateral portal vein) PVTT who underwent hepatectomy and those treated with sorafenib were included. Treatment results were compared between the two modalities for each PVTT category, and a propensity analysis was performed for patients with Vp3 and Vp4 (Vp3/4). The median survival times (MSTs) of patients with Vp2, Vp3, and Vp4 PVTT who underwent hepatectomy were 21.4, 13.6, and 14.9months, respectively; the MSTs for those with Vp2, Vp3, and Vp4 PVTT who received sorafenib treatment were 6.9, 5.5, and 3.6months, respectively, with a significant difference. In a propensity-matched cohort of patients with Vp3/4 PVTT (36 patients in each), the MST of patients who underwent hepatectomy (15.1months) was significantly better than the patients treated with sorafenib (4.5months). Hepatectomy can be associated with prolonged survival in HCC patients with macroscopic PVTT.

OUTCOMES IN PRIMARY UNCOMPLICATED RHEGMATOGENOUS RETINAL DETACHMENT REPAIR USING PARS PLANA VITRECTOMY WITH OR WITHOUT SCLERAL BUCKLE.

To compare outcomes after primary uncomplicated rhegmatogenous retinal detachment repair using pars plana vitrectomy (PPV) or PPV with scleral buckle (PPV-SB). This is a retrospective cohort study with propensity score analysis in a single tertiary care center between 2014 and 2018 comparing patients with primary uncomplicated rhegmatogenous retinal detachment repaired using PPV only or PPV-SB (full cohort: n = 1,516, propensity-matched cohort: n = 908). The primary outcome was single surgery anatomic success, whereas secondary outcomes were 3-month and final pinhole visual acuity in logarithm of the minimum angle of resolution and final retina status. In the full cohort, single surgery anatomic success was achieved in 745 (91%) PPV patients versus 623 (89%) PPV-SB patients (P = 0.13). This was 390 (92%) versus 314 (88%) in phakic patients (P = 0.06) compared with 353 (91%) versus 301 (90%) in pseudophakic patients (P = 0.79), respectively. After matching, single surgery anatomic success was achieved in 424 (93%) PPV patients versus 412 (91%) PPV-SB patients (P = 0.14). Median pinhole visual acuity after PPV was better at 3 months (PPV: 20/40 vs. PPV-SB: 20/50; both cohorts: P < 0.001) and final follow-up (PPV: 20/29 vs. PPV-SB: 20/38; full cohort: P < 0.001 and PPV: 20/29 vs. PPV-SB: 20/36; matched cohort: P < 0.001). Addition of scleral buckle does not significantly change the rate of single surgery anatomic success compared with PPV only in primary uncomplicated rhegmatogenous retinal detachment. It is also associated with worse pinhole visual acuity at follow-up.

Initial Invasive or Conservative Strategy in Heart Failure With Preserved Ejection Fraction and Coronary Artery Disease.

BackgroundIn patients with both heart failure with preserved ejection fraction (HFpEF) and coronary artery disease (CAD), whether adopting an initial invasive strategy benefits better in clinical outcomes compared with those who received an initial conservative strategy remains inconclusive.MethodsWith data from the heart failure (HF) cohort study, we analyzed patients who had HFpEF and CAD amenable to the invasive intervention using propensity score matching of 1:1 ratio to compare the initial invasive strategy and the initial conservative strategy of medical therapy alone. The primary outcome was the composite endpoints of all-cause mortality or cardiovascular hospitalization, and the secondary outcome was all-cause mortality or cardiovascular hospitalization.ResultsOf 1,718 patients, 706 were treated with the invasive strategy and 1,012 with the conservative strategy initially. Propensity score matching was used to assemble a matched cohort of 1,320 patients receiving the invasive intervention (660 patients) or the medical therapy alone (660 patients). With a follow-up of 5 years, 378 (57.3%) in the invasive-strategy group and 403 (61.1%) in the conservative-strategy group reached the primary endpoint, and there was no significant difference in the rate of the primary endpoint (P = 0.162). The initial invasive strategy only improved the secondary outcome of cardiovascular hospitalization (P = 0.035). Also, the multivariable Cox regression model revealed that antiplatelet therapy, angiotensin-converting enzyme inhibitor/angiotensin II receptor blocker (ACEI/ARB), or statin prescription was associated with a decreased risk of the primary outcome.ConclusionIn this well-profiled, propensity-matched cohort of patients with HFpEF and CAD, the addition of invasive intervention to medical therapy did not improve the long-term composite of all-cause mortality or cardiovascular hospitalization.

Bariatric Tele-screening During the COVID-19 Pandemic: Holding Back for Direct Approval?

PurposeMany bariatric centers were restricted from providing routine care for outpatients. Telehealth visits allowed the continued care for outpatients and thus the preoperative screening for bariatric candidates. The objective of this study was to evaluate the effect of tele-screening on the multidisciplinary obesity team’s decision (MDD) for bariatric surgery: disapproval, direct approval, or a recommendation for a prehabilitation program.Materials and MethodsHospital data were collected from patients who underwent face-to-face or tele-screening for bariatric surgery between April and December 2020. The tele-screening cohort was then compared with a propensity-matched cohort of patients with face-to-face consultations. A chi-square and multinomial logistic regression analyses were performed.ResultsAfter propensity matching, 396 patients remained for analysis. The majority received preoperative prehabilitation advice in both the tele-screening and face-to-face group (51% versus 50%). Although not significant, there were more direct approvals and fewer denials in the face-to-face group (p = 0.691). The multinomial logistic regression analysis showed no significant impact of tele-screening on the MDD result.ConclusionTele-screening in bariatric centers is feasible; the multidisciplinary team’s decision was not significantly different between tele-screening and face-to-face screening which encourages the use of tele-screening in the future. An insignificant amount of fewer direct approvals and more denials were observed in the tele-screening group, which should be taken into account in future and larger case studies.Graphical abstract

Outcomes of SARS-CoV-2 infection in patients with celiac disease: a multicenter research network study.

BackgroundCeliac disease (CD) is associated with an increased risk for respiratory infections and severe outcomes. No data have been reported in the scientific literature regarding the outcomes of COVID-19 in this population. The aim of this study was to report matched clinical outcomes in a large cohort of 930 patients with COVID-19 in the setting of known CD.MethodsAnalysis of a multicenter research network TriNETX was performed, including COVID-19 patients aged more than 16 years. Outcomes of COVID-19-positive patients with concurrent CD were compared with a propensity-matched cohort of patients without CD.ResultsA total of 341,499 patients with SARS-CoV-2 infection were identified on the research network: 930 (0.27%) with CD and 340,569 (99.73%) without CD. In the 30- and 60-day periods post SARS-CoV-2 infection, 12 (1.29%) and 13 (1.40%) deaths, respectively, were reported in the CD group. Fewer patients in the CD group reached the composite outcome of either mechanical ventilation or mortality at 60 days (risk ratio 0.58, 95% confidence interval 0.36-0.95). After propensity matching, no difference in clinical outcomes was observed.ConclusionOur data suggest that patients with CD are not at increased risk of COVID-19-related morbidity or mortality.

Comparison of Sutureless Bioprosthetic Valve With Surgical or TAVR for SevereAortic Stenosis.

Clinical advantages of sutureless rapid-deployment (RD) aortic valve replacement (AVR) for severe aortic valve stenosis (AS) have not been elucidated compared with surgical (SAVR) or transcatheter (TAVR) aortic valve replacement. This study sought to investigate comparative effectiveness and safety of RD-AVR compared with SAVR and TAVR in a prospective cohort of patients with severe AS. The primary outcome was a composite of death, stroke, or rehospitalization at 12months. Propensity score matching was used to assemble a cohort of patients with similar baseline characteristics. Among 1,020 eligible patients, 107 (10.5%) underwent RD-AVR, 437 (42.8%) underwent SAVR, and 476 (46.7%) underwent TAVR. In the matched cohorts of RD-AVR and SAVR (n=107), the incidence of primary composite outcome at 12months was similar between the 2 groups (8.0% vs 10.8%, respectively; hazard ratio [HR]: 0.74; 95% confidence interval [CI]: 0.30-1.84; P=0.52). In the matched cohorts of RD and TAVR (n=58), the incidence of primary composite outcome at 12months did not statistically differ between the 2 groups (9.4% vs 16.2%, respectively; HR:0.53; 95%CI: 0.18-1.57; P=0.25). In this propensity-matched cohort of patients who underwent AVR for severe AS, we did not detectsignificant differences in the rates of the primary composite of death, stroke, or rehospitalization at 12months when comparing RD-AVR with SAVR and TAVR. Because the study was underpowered, the results should be consideredas hypothesis generating highlighting the need for further research. (ASAN Medical Center Aortic Valve Replacement Registry [ASAN-AVR]; NCT03298178).

Venetoclax and azacitidine compared with induction chemotherapy for newly diagnosed patients with acute myeloid leukemia

AbstractVenetoclax (ven) plus azacitidine (aza) is the standard of care for patients with newly diagnosed acute myeloid leukemia (AML) who are not candidates for intensive chemotherapy (IC). Some patients who are IC candidates instead receive ven/aza. We retrospectively analyzed patients with newly diagnosed AML who received ven/aza (n = 143) or IC (n = 149) to compare outcomes, seek variables that could predict response to 1 therapy or the other, and ascertain whether treatment recommendations could be refined. The response rates were 76.9% for ven/aza and 70.5% for IC. The median overall survival (OS) was 884 days for IC compared with 483 days for ven/aza (P = .0020). A propensity-matched cohort was used to compare outcomes in the setting of equivalent baseline variables, and when matched for age, biological risk, and transplantation, the median OS was 705 days for IC compared with not reached for ven/aza (P = .0667). Variables that favored response to ven/aza over IC included older age, secondary AML, and RUNX1 mutations. AML M5 favored response to IC over ven/aza. In the propensity-matched cohort analyzing OS, older age, adverse risk, and RUNX1 mutations favored ven/aza over IC, whereas intermediate risk favored IC over ven/aza. In conclusion, patients receiving IC have improved OS compared with those receiving ven/aza. However, in a propensity-matched cohort of patients with equivalent baseline factors, there was a trend toward favorable OS for ven/aza. Specific variables, such as RUNX1 mutations, reported here for the first time, can be identified that favor ven/aza or IC, helping to guide treatment decisions for patients who may be eligible candidates for either therapy.

Catastrophic health expenditures, insurance churn, and nonemployment among gynecologic cancer patients in the United States

In recent years, there has been growing recognition of the financial burden of severe illness, including associations with higher rates of nonemployment, uninsurance, and catastrophic out-of-pocket health spending. Patients with gynecologic cancer often require expensive and prolonged treatments, potentially disrupting employment and insurance coverage access, and putting patients and their families at risk for catastrophic health expenditures. This study aimed to describe the prevalence of insurance churn, nonemployment, and catastrophic health expenditures among nonelderly patients with gynecologic cancer in the United States, to compare within subgroups and to other populations and assess for changes associated with the Affordable Care Act. We identified respondents aged 18 to 64 years from the Medical Expenditure Panel Survey, 2006 to 2017, who reported care related to gynecologic cancer in a given year, and a propensity-matched cohort of patients without cancer and patients with cancers of other sites, as comparison groups. We applied survey weights to extrapolate to the US population, and we described patterns of insurance churn (any uninsurance or insurance loss or change), catastrophic health expenditures (>10% annual family income), and nonemployment. Characteristics and outcomes between groups were compared with the adjusted Wald test. We identified 683 respondents reporting care related to a gynecologic cancer diagnosis from 2006 to 2017, representing an estimated annual population of 532,400 patients (95% confidence interval, 462,000-502,700). More than 64% of patients reported at least 1 of 3 primary negative outcomes of any uninsurance, part-year nonemployment, and catastrophic health expenditures, with 22.4% reporting at least 2 of 3 outcomes. Catastrophic health spending was uncommon without nonemployment or uninsurance reported during that year (1.2% of the population). Compared with patients with other cancers, patients with gynecologic cancer were younger and more likely with low education and low family income (≤250% federal poverty level). They reported higher annual risks of insurance loss (8.8% vs 4.8%; P=.03), any uninsurance (22.6% vs 14.0%; P=.002), and part-year nonemployment (55.3% vs 44.6%; P=.005) but similar risks of catastrophic spending (12.6% vs 12.2%; P=.84). Patients with gynecologic cancer from low-income families faced a higher risk of catastrophic expenditures than those of higher icomes (24.4% vs 2.9%; P<.001). Among the patients from low-income families, Medicaid coverage was associated with a lower risk of catastrophic spending than private insurance. After the Affordable Care Act implementation, we observed reductions in the risk of uninsurance, but there was no significant change in the risk of catastrophic spending among patients with gynecologic cancer. Patients with gynecologic cancer faced high risks of uninsurance, nonemployment, and catastrophic health expenditures, particularly among patients from low-income families. Catastrophic spending was uncommon in the absence of either nonemployment or uninsurance in a given year.

Cost-Benefit Analysis of Robotic vs. Laparoscopic Hepatectomy: A Propensity-Matched Retrospective Cohort Study of American College of Surgeons National Surgical Quality Improvement Program Database.

Robotic and laparoscopic hepatectomies having increased utilization as minimally invasive techniques are explored for hepatobiliary malignancies. Although the data on outcomes from these 2 approaches are emerging, the cost-benefit analysis of these approaches remains sparse. This study compares the costs associated with robotic vs. laparoscopic liver resections, taking into account 30-day complications. Using the American College of Surgeons National Surgical Quality Improvement Program database, a propensity-matched cohort of patients with laparoscopic or robotic liver resections between 2014 and 2017 was identified. Costs were assigned to perioperative variables, including operating room (OR) time, length of stay, blood transfusions, and 30-day complications. Cost estimates were obtained from the Centers for Medicare and Medicaid Services billing data (2017), American Hospital Association data (2017), relevant literature, and local institutional cost data. In our matched cohort of 454 patients (227 per group), total costs associated with laparoscopic liver resections were estimated at $5.5M ($24K per patient) vs. $6.8M ($29.8K per patient) for robotic liver resections (21.3% difference, P < .001). The higher cost associated with robotic hepatectomies was related to blood transfusions ($22.0K vs. $12.1K, P = .02), length of stay ($2.05M vs. $1.76M, P = .046), and OR time ($4.01M vs. $3.24M, P < .0001). Robotic hepatectomies were associated with higher costs compared to laparoscopic hepatectomies. The 2 major contributors to the cost disparity were increased OR time and increased length of stay. Future studies are warranted to analyze high-volume Minimally Invasive Surgery surgeons' impact in specialty centers on potentially mitigating this current cost disparity.

Transanal versus conventional total mesorectal excision for rectal cancer using the IDEAL framework for implementation.

BackgroundTransanal total mesorectal excision (TaTME) is an innovative technique for distal rectal cancer dissection. It has been shown to have similar short-term outcomes to conventional open and laparoscopic total mesorectal excision (cTME), but recent studies have raised concern about increased morbidity and local recurrence rates. The aim of this study was to assess outcomes after TaTME versus cTME for rectal cancer.MethodsTaTME was implemented in 2014 using IDEAL principles in a single institution. The institution maintains databases for all patients undergoing rectal cancer surgery. This retrospective review compared data collected from all patients who had TaTME with those from a propensity-matched cohort of patients who underwent cTME. The primary outcome was a composite pathological measure combining margin status and quality of total mesorectal excision (TME). Short-term clinical and survival outcomes were also measured.ResultsPropensity matching created 109 matched pairs for analysis. Nine patients (8.3 per cent) undergoing TaTME had positive margins and/or incomplete TME, compared with 11 (10.5 per cent) undergoing cTME (P = 0.65). There were no significant differences in morbidity between the TaTME and cTME groups, including number of anastomotic leaks (13.8 versus 18.3 per cent; P = 0.37). The estimated 3-year local recurrence-free survival rate was 96.3 per cent in both groups (P = 0.39). Estimated 3-year overall (93.6 per cent for TaTME versus 94.5 per cent for cTME; P = 0.09) and disease-free (88.1 versus 76.1 per cent; P = 0.90) survival rates were similar.ConclusionTaTME provided similar outcomes to cTME for rectal cancer with the application of IDEAL principles.